Abrupt Discontinuation Versus Taper of Hydrocortisone in Patients With Septic Shock

Abstract

Background: Although not mentioned in the most recent guidelines, the 2016 Surviving Sepsis Campaign guidelines recommend to taper corticosteroids once vasopressors are no longer needed; however, at the time of publication, there were no studies comparing taper versus abrupt discontinuation of corticosteroids. Objectives: The purpose of this study was to further evaluate the impact of abrupt versus taper discontinuation of corticosteroids in septic shock. Methods: This was a retrospective cohort study that included patients who received an initial dose of 200 to 300 mg of hydrocortisone for septic shock. Participants were then divided into “abrupt” and “taper” groups. The primary outcome assessed was hemodynamic instability during taper or within 72 hours of the last corticosteroid dose. Secondary outcomes included intensive care unit (ICU) and hospital length of stay, incidence of hyperglycemia or hypernatremia, and in-hospital mortality. Results: The primary outcome of reinitiation of vasopressor therapy occurred in a larger proportion of patients in the taper group compared with the abrupt group (21.9% vs 10.7%). The ICU length of stay (7.6 days abrupt vs 9 days taper) and hospital length of stay (14.9 vs 15.3 days) were similar between groups. There was a statistically significant increase in patients who experienced hyperglycemia within 24 hours of the last corticosteroid dose in the abrupt group. All other secondary outcomes were similar between groups. Conclusions: The abrupt discontinuation of hydrocortisone in the treatment of septic shock was associated with a nonstatistically significant 50% absolute reduction in the need for vasopressor reinitiation.

Sepsis and Adrenal Insufficiency

“…A recent retrospective study showed that abrupt discontinuation of corticosteroids was associated with a lower likelihood of vasopressor reinitiation when compared with taper discontinuation. 51 In the event of shock recrudescence, the decision to reinstitute hydrocortisone should be tailored to the specific clinical circumstances. Our recommendations regarding corticosteroid administration in various systemic inflammatory processes are summarized in Table 2.…”